173 Arrowhead Rd .� �� DAVIE COUNTY ENVIRONMENTAL HEALTH
P.O.Bpx 848/210 Hospital Street
Mocksville,NC 27028
(336)'751-8760 F�#(336)751-8786
OPER�ITION PERMIT
Account #: 990004185 Tax PIN/EH #: 5853-46-4444
Billed To: Paul Spiilman Subdivision Info:
Reference Name: Location/Address: Arrowhead Road-27028
Proposed Facility: Residence Property Size: 2 Acres
ATC Number. 4568
**NOTE**The issuance of tlus Operadon Pernut shall indicate the system described on the ATC has been installed
in compliance with Article 11 of G.S. Chapter 130A, Secrion.1900"Sewage Treatment anct Disposal Systems,"
but shall in NO WAY be taken as a guarantee that the system will function sarisfactorily for any given period of
time.
System Type:�_,.,S.T.Manufacturez`���� Tank Date_�1��Fank Size r" �O c�
Pump Tank Size �
System Installed By:_��.a �� ��_E.H. Specialist: �� v�ate: 1 3 C� '� ()�f
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DCHD 11/06(Revised)
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' ` DAVIE COUNTY ENVIRONIVIENTAL HEALTH ��
P.O.Box 848/210 Hospital Street
Mocksville,NC 27028 �}
(336)751-8760 Fax#(336)751-8786 �l l/��
AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION
Account #: 990004185 Tax PIN/EH #: 5853-46-4444
Billed To: Paul Spillman Subdivision Info:
Reference Name: Location/Address: Arrowhead Road-27028
.Proposed Facility: Residence Property Size: 2 Acres
ATC Number: 4568
**NOTE**This Authorization to Construct(ATC)MUST BE ISSUED by the Davie Cowuy Environmental
Health Section prior to issuance of any building permit(s),(in compliance with Article 11 of G.S. Chapter 130A
Wastewater Systems, Section.1900 Sewage Treatment and Dispos�ll Systems). THIS AiJTHORIZATION TO
CONSTRUCT IS VALID FOR A PERIOD FIVE Y�ARS. Tlus ATC is subject to revocaUon if site plans,plat or
the intended use change.
Residential Spec�cadon:BuildingType�,a #Peaple � #Bedrooms 3 #Baths 2
Basement w/Plumbing:,_,_Basement/No Plumbing y
Commercial Specification:Facility Type #People #People/Shift #Seats
Lot Size Type Water Supply pesign Wastewater Flow(GPD) Site:New Repair
System Specifications:Tank Size I�occ�GAL.Pump Tank^G,AL.Trench Width � Trench Depth 2!�—3 L�
Rock Depth�" Linear Ft. k�o
As �tated in 15A RCF:C 184.156p(5�
Other: �,�,,�.,��s--t�ap-a+��-i�:�-xis,;
Required Site Modifications/Conditions:
Contact the Davie County Environmenfai Health Section for final inspection of this system betweera
8:30—9:30a.m,on the da of installation. Tele hone#(336 751-8760.
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Environmental Health Specialist � �'�/ Date: �C� � 7
DCHD 11/06(Revised)
7 +
;;:-. , ;;; `�iPPL1C�TI01�1�'1+ R SITE EVALUATION/IMPROVEMENT PERMIT & ATC .
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�1'� '�t t' � ` �{� � 1'� Davie County Environmental Health
'�,�� �F�:� � P.O.Box 848/210 Hospital Street
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��`t ��, �," � 'i �' '^ '� q"�r Mocksville,NC 27028
iJ: �- -.-,�.;4 (336)751-8760/Fax(336)751-8786
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Applicafion For ❑ Site,Evaluatio ' mprovement Permit ❑ Authorization To Construct(ATC) �Both
T e_of Application: ❑New System ❑Repair to Existing System ❑Expansion/Modification of Existing System or Facility
***IMPORTANT***THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL OF THE REQUIRED
INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions.
APPLICANT INFORMATION
Name to be Billed � .� '��l l
� Contact Person j C�'Y1 �
Billing Address �� Y'�c,;,., Gti Home Phone .3j(c• �t �i �- .�.��'S
City/State/ZIP � k S�' C, U 3' Business Phone 3�(�� �i L�� -:�/C `f
Name on PermidATC if Different than Above
Mailing Address City/State/Zip
PROPERTY INFORMATION *Date House/Facility Corners Flagged �I L1 =,
NOTE: A survey plat or site plan must accompany this application. Included: ❑ Site Plan ❑Plat(to scale)
(Pernut is v lid for 60 months wi�h site plan,no expiration with complete plat.)
Owner's Name �C.�l,`�� � Phone Number ,3.3(,�-- �� �' - �j��
Owner's Address 1�3 MU � ���cl �• City/State/Zip /�{.r�KS V�l l N_ ��C; 2 7c 2�
Property Address JJ'' City
Lot Size Tax PIN# $�j"} -�-{ (��- 1-� y L{i.�.
Subdivision Name(if applicable) Section/Lot# �)
Directions To Site: I S� -�u F�. n ('c.c� . _��, �d . �„� �., �,.� �" I c> f , �" C�7'c�� rc�cJ�
�
� rn�1�� 'n� S�i11��N,, �1 ��, 1 zf� �>o►t�rnL�� �-h� 'At�,�.,:.:���«d cn r�al�# � L.�++ hr s��� ��ul�(e. �::�I�
If the answer to any f the following questions is"yes',supporting documentation must be attached. �>n ��'(:.�
Are there any existing wastewater systems on the site? �Yes QNo
Does the site contain jurisdictional wetlands? ❑Yes C�}iQo
Are there any easements or right-of-ways on the site? ❑Yes Cs�1�10
Is the site subject to approval by another public agency? ❑Yes C3'No
Will wastewater other than domestic sewage be generated? ❑Yes �fo
IF RESIDENCE FILL OUT THE BOX BELOW
#People ����/�#Bedrooms �' #Bathrooms Garden Tub/Whirlpool ❑Yes
Basement: ❑Yes f�o Basement Plumbing: ❑Yes ❑No
IF NON-RESIDENCE FILL OUT THE BOX BELOW
Type of FacilityBusiness Total Square Footage of Building #People
#Sinks #Commodes #Showers #Urinals
Estimated Water Usage(gallons per day) (Attach documentation of similar facility water consumption)
FOODSERVICE ONLY: #Seats
Type systemrequested: L�t;onventional ❑Accepted ❑Innovative ❑Alternative ❑Other
Water Supply Type: ❑ County/City Water C�New Well ❑Existing Well ❑ Community Well
Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes E�10
If yes,what type?
This is to certify that the information provided on this application is hue and correct to the best of my knowledge. I understand that
any pernut(s)or ATC(s)issued hereafter are subject to suspension or revocation if the site is altered,the intended use changes,or if
the information submitted in this application is falsified or changed. I hereby grant right of entry to the Authorized Representative
of the Davie County Health Department to conduct necessary inspections to detemune compliance with applicable laws and rules.
I understand that I am responsible for the proper identification and labeling of property lines and corners and locating and flagging
or staking the house/facility location,proposed well location and the location of any other amenities.
Q� �� 5���-r-�'� Site Revisit Charge
Property owner's or wner's legal representative signature
Date(s):
� r 0�, Client Notification Date:
Date EHS:
i
Sign given Yes ❑No " Account# �J
Revised 11/06 Invoice#
' ' � DAVIE COUNTY HEALTH DEPARTMENT
� ' � Environmentai Health Section
Soil/Site Evaluation
APPLICANT INFORMATION PROPERTY INFORMATION
Account #: 990004185 Tax PIN/EH#: 5853-46-4444
Billed To: Paul Spillman Subdivision Info:
Reference Name: Location/Address: Arrowhead Road-27028
Proposed Facility: Residence Property Size: 2 Acres Date Evaluated: ( -1 (e-U�
Water Supply: On-Site Well � Community Public
�;'
Evaluation By: Auger Boring �� Pit ` Cut
FACTORS 1 , 2 �' 3 4 5 6 7
Landsca e sition L 5 -' LL S L V
Slope % 3 � `w �
HORIZON I DEPTH ,-�y �•
Texture grou G L
Consistence Q
Structure ^
Mineralo �: / 1�' (
HORIZON II DEPTH -�(�
Texture rou G �'' ,
Consistence ..+�� ' -
Structure ' �' t
Mineralo �: I t , C
HORIZON III DEPTH C "` N �J
Texture rou '�
Consistence ;P � �{
Structure
Mineralo
HORIZON IV DEPTH
Texture rou
Consistence
Structure
Mineralo
SOIL WETNESS
RESTRICTIVE HORIZON
SAPROLITE
CLASSIFICATION ; ' .Sw:1�I;le
LONG-TERM ACCEPTANCE RATE C)�'� - '� 1..
SITE CLASSIFICATION: �'.J �t � � �i tf EVALUATION BY: �C c% �J' J�'!Y c��-r .`�
�
LONG-TERM ACCEPTANCE RATE: �• �� OTHER(S)PRESENT:
REMARKS:
LEGEND
T,�ndscape Position
R-Ridge S -Shoulder L-Linear slope FS -Foot slope N-Nose slope .
CC-Concave slope CV-Convex slope T-Tenace FP-F1ood plain H-Head slope
Tsxturg
S -Sand LS-Loamy sand SL-Sandy loam L-Loam SI-Silt
SICL-Silty clay loam SIL-Silty loam CL-Clay loam SCL-Sandy clay loam
SC-Sandy clay SIC-Silty clay C-Clay
('ON4I�T�.N . .
aZ41S�
VFR-Very friable FR-Friable FI-Firm VFT-Very�rm EFI-Extremely�rm
� �
NS -Non sticky SS -Slightly sticky S-Sticky VS -Very Sticky
NP-Non plastic SP-Slightly plastic P-Plastic VP-Very plastic .
Structure
SC-Single grain M-Massive CR-Crumb GR-Granular ABK-Angular blocky
SBK -Subangular blocky PL-Platy PR-Prismatic
Mineraloev
1:1,2:1,Mixed
Notes
Horizon depth-In inches
Depth of�11-In inches
Restrictive horizon-Thickness and inches from land surface
Saprolite-S(suitable),U(unsuitable)
Soil wetness-Inches from land surface to free water or inches from land surface to soil colors with chroma 2 or less
Classification-S(suitable),PS(provisionally suitable),U(unsuitable)
LTAR-Long-term acceptance rate-gal/day/ft2 DCHD OS/OS (Revised)
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Surveyors Certification Surveyors Certification for Subdivision Planning Deportment / Review Officer Davie County Register of Deeds
JERRY PATRICK JULLARA PLS JERRY PATRICK li&LARD aerWy to one or nwre of the
RealflNd Rona atlq ad Mb fd ow dwo b w� L Pretseeiotnd Land SMrrveyar, Nlurnb.r �-�7 as indicated by an x: final Subdivision Plot Approval Plat Registration
a alsel=Vq cob-dr ver Inviogwo(60"M eeoerd I M Dai Doer ShOW- A. That tow .plat s of o survey the timet - a subdivition of and within the ono of a oounty or municipow Thk k W armor Met MI Md cede to raeniy re�r6t.sde d Mr RM FOR R6aaDaoil I' OUM r
Ilya HK'eOn ) IM1 be rate d peenu a afe1ldea am ob I:NLM 64 That has on airdinorros that 'amass of and; D mwourt 0 - - ""in�a Nr a"C�
Mei tib w b aardrtes Wb a s 47-36 a aradei B. That Mico /id w of a as vey�wooled In such portion of o county or nwnidpolity that is unrequkAnd y�Cyt d OM cook amity This� 200111
c +7
Siff •• - dowON& C. That taco p10 as to an d survey and erdsis of W4 poroai or pareda d bnd; Met ver veep or Met W Wft Mie w8ludoo M diad colo a isWry a1 aerrN a 11rt ft* d r
Arrowhead Road +�"�'�
SR 1459 3 �1F7ML-1297 D. That this pat w d a surrey d onottw category. such as the recombination of rem d owe
X ordered survey or oMnsr exception to the deffffton of a subdivision; exwfkq QO�°a' ° °tet it ~001W
Land Surveyor Ucectsd Number E. TAat 1W Information ovolobw to this sunsyor is such that t am unaMe to maks a dsrKmtnation to the test Olrwrr d Dallier M,
tae w ogy of ^'�. 2006 of ability as, to provwtons oontdned In A. through D. oboes. Thi w Dotal 1006
/ Assistant Deputy
Spik]nnrt Rona DAVIE COUNTY-NORTH CAROLINA � � T<� L-1297 DAVIE COLiNTY, NORTH CAROLINA DAVIE COUNTY. NORTH CAROLINA
SR 1458 %00 '*" Pref lanai Lend Surveyor Ueenee Number DAVIE COUNTY-NORTH CAROLINA
Q. OfESSip \
NOW OR FORMERLY Q;Q4` ':y NOV OR FORMERLY t
FARMNGTON NC Highway 901 GEORGE WILSON _ t S E A L ._ \ f�eldfi►e/d Road HARRY MYERS
L-1297 60' P"07E EASf�II r 14' 6MWL 8040
DD ]48 PG 756 _ � DB 111 PG 443
SEE PLAT BON( 6 PAGE I ' v <% ��o \ � �( 148 PAGE 756 SEE PLAT BOOK 4 PAGE 54
, sulr���' - \ PLAT 9" 6 PAGE 1 LOT No. s
Location Map --- Not To Scale ,�''y�TRICK•�J�~�� 30'00' EXIriTING
, PPE
T _ - E INCHES DEEP -
N 88'28'00' E
_- -_ 827'1 ' E _ --- -'-'- ----_-_a ---- _ ---------
-- -------- -
a --------------- --
`f
I
___
ESTG297.63'_ �
---_--- -- ---- 3/4' PIPE
1 FOOT DEEP -
_ NO APPROVAL REQUIRED BY THE DAVIE COUNTY PLANNING DEPARTMENT '
EXISTING ' '
Control Corner, 5/fr ROW EXISTING NCDOT
EXISTING
R/W DISC ' 1
5/8' REBAP N ( %4104% DIRECTOR DATE
LINE I DIRECTION ST
L-I N 27' 4' W 11.41' ro `
r^
'4
1
HAROLD E. SHREWSBURY H
DB 192 PG 543
MICHAEL LEE POE
DB 184 PG 801
SEE PLAT BONG 6 PAGE 1 $ a'
m
c � ' 1 STATEMENT OF OVNERSHIP AND DEDICATI0N
+� I (WE) HEREBY CERTIFY THAT I AM (WE ARE) THE OWNER(S) OF THE
PROPERTY DESCRIBED HEREON, WHICH IS LOCATED IN THE SUBOMSION
�o JURISDICTION OF DAVIE COUNTY AND THAT I HEREBY ADOPT THIS SUBDMSION
5853-46-4444 ` I PLAN WITH MY FREE CONSENT, ESTABLISHED MINIMUM BUILDING SETBACK
LINES AND DEDICATE ALL STREETS, ALLEYS, WALKS, PARKS AND OTHER SITES
WILLIAM W. SPILLMAN JR. ET AL ` AND EASEMENTS TO PUBLIC OR PRIVATE USE AS NOTED.
DB 315 PG 819
q� SEE PLAT BOOK 6 PAGE I FYISTINt I -- ---- SINE(
S 88'27'58' W
i1/8- PEW N 88'27'58' E 291.23' Total ; i DATE OWNER
TRACT 3 270.42' I --,---- ;IGNED
142.28' NEW IRON SET DATE OWNER
\ 5.808 ACRES NEW IRON SET 3/9' STEEL ROD - SIGNED
\ 3/Ir STEEL ROD 1 1 DATE OWNER
i
SIGNED
W DATE OWNER
1
J� r a TRACT 2 1 �,
o
2.000 ACRES
H U
( N 1 NOW OR FORMERLY
/ r+n FRED SMITH
�.� SEE PLAT BOOK 4 PAGE 54
NEW IRON SET LOT NO. 1'
3/r STEEL RtJO
S83.14'14• E NEW IRON SFT `
31T STEEL RUO I 1
/ Leh* 200.66,
NEN IRON SFT
f
s
93*14'14" E 3/i' S»� ROD ARROWHEAD ROAD / SR x459
�Q3' g! a 287.00' Total
IN + 261.24TRACT 1 I 1 50' PUBLIC R16NT OF WAY/ 19' PA I0 RW
r.r 0.331 ACRES
W
'
1001 S / EXISTING N 83.14'14' V 14,425 SQ FT o u
y' 1
c-o r d J7? �9- I. PPE 1 PIPE 290.00' °D
CD f 12 U�@ 4��- F EXISTING c
\, fn
'4c, p0* \ - INSET - T-IRON i
NOT TO SCALE ®4.51' H NOTE: TRACT NO. 1 TO BE COMBINED WITH RECORD PLAT FOR
\ PAUL M. SPILLMAN'S EXISTING LOT.
Bahr f or a�
°F W//&M W SDA/Jean 4*,
\ N PALL M SPILLMAN 0•
Pau/ M. saw T&ry s 6WIl rmn
LU
Lj LEGEND
DB 092 PG 549
AND Qvd Si HWch&w
n PROPERTY LINE Control Corner \ (:7E;XtSTW:
RIGHT OF WAY LINE EXISTING N 83'16'28' W SEE SURVEY BY, GRADY TUTTEROW, PLS T.� i I ! I
------- LITE "401H DEED OR PLAT I' PIPE �\ 324.49' Total Dnteob s-2t-1996 Mop N ]1996-2 INSET REFERENCE DEED: DEED BOOK 315 PAGE 819
N/F NOV OR FORMERLY . -� EXISTING
- -
z DB DB DEED SUM �\ � � 36 61' I' PPE NOT TO SCALE
I I BEING A OMSION Of PIN NUMBER: 5853-46-4444
PA
PB PLAT BI]OI(
�, �~�'�' F. DONALD POINDExTER \ alrPIPE
�C FARYINGTON TOWNSHIP DAVI>r. COUNTY, N.C.
DMD DOUBLE NERIDAN DISTANCE /
Q EIP ( EXISTING IRON FOUND > �f In DB 095 PG 060 _ DATE: DECEYHER 1 2008 SCALE: 1" 80'
Q NIP ( NEW IRM SET ) \ • Q� 3'
0 POINT ( Nil KWHENTATION SET ssSEE PLAT BONG 4 PAGE 54 T _ - INSET - I� I TMAL ACRES BY DHD = 8.139
Z 0 GRANITE TO4i1nENT ` LOT NO. 3 EXISTMIG le
EXISTING NAIL ' T°•�� GRAPHIC SCALE T_" I� PLOT TO SCALE I f f� Y Adr".A, per,
Q 60 0 30 so 120 ��—� 240 ! PROFESSIONAL LAND SURVEY13R
EXISTING SET STONE \ 1 4 3942 VELCD STREET
M �, uTntTY PpIE VNSTUN-SALEK NORTH CAROLDM 27107
-- TELEPHMC, 336 / 789-0145
Q NCDUT R/W DISC NOTE, NO NCGS HORIONTAL CONTROL FOUND
VITHIN 2000' OF THIS PROPERTY.
I inch = 60 ft SHEET 1 OF 1 JOB NO: 1116-06C
, �
� ,.
Davie County Environmental Health
P.O.Box 848l210 Hospital Street
Mocksville,NC 27028
(336)751-8760/Fax(336)751-8786
IMPROVEMENT PERMIT
� Account #: 990004185 " Tax PIN/EH #: 5853-46-4444 ' `
Billed To: Paul Spillman Subdivision Info:
Address: 173 Arrowhead Road Location/Address: Arrowhead Road-27028
City: Mocksville Property Size: 2 Acres
Reference Name:
Proposed Facility: Residence
**NOTE**This Improvement Permit DOES NOT authorize the construction of a wastewater system. An
Authorization To Construct a wastewater system must be obtained from this office prior to the
construction/installation of a wastewater system or the issuance of a building permit(in compliance with
Article 11 of G.S. Chapter 130A,Wastewater Systems). This Improvement Permit is subject to
revocation if site plans,plat or the intended use change.
Permit Type: Q�Tew ORepair ❑Expansion Pemut Valid for: Years ❑No Expiration
Residential Specifications: #Bedrooms � #Bathrooms r� #People � Basement❑ Basement plumbing❑
Non-Residential Specifications: Facility Type #People #Seats
Square Footage(or Dimensions of Facility)
Design Flow(GPD): �� Type of Water Supply: ❑County/City NYWeIl ❑Community Well
As �tated in 15A RCAC 18.��.19Ep(5�
Site Modifications/Permit Conditions: �obe���S���a,�Ts� �_ _ Jv
S stem T e LTAR
Initial �I ,al
Re air �L �.�.�''
Site lan
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Environmental Health Specialist �f�l� � Date�l� `D' 7
i.p.l 1-06